The many faces of Akathisia

Abstract

Akathisia, a common side effect of neuroleptic therapy, is an emotional state and “refers not to any type or pattern of movement, but rather to a subjective need or desire to move.” 1,2 Akathisia, in contrast to the other drug-induced extrapyramidal reactions, is subjective, and for this reason it may be difficult to diagnose. Historically, the predominant mental manifestations of akathisia have caused confusion. Haskoves, 3 who originally described the syndrome in 1901, concluded that the disorder was of hysterical origin. Bing 4 viewed akathisia as a “psychosis” characterized by a “morbid fear of sitting down,” but in another chapter he explained it as a way of overcoming the muscular rigidity of Parkinson's disease. Oppenheim 5 considered akathisia as a form of neurosis, “usually a form of phobia.” Wilson 6 designated it “hysterical” in one chapter of his classic textbook, but he also described the syndrome in association with Parkinson's disease in a later chapter. Akathisia can be mistaken for an exacerbation of the original mental illness. 7–9 Hodge 10 stated that akathisia “may appear like an anxiety state… in which real anxiety can be neither recognized nor verbalized.” Raskin 11 found that patients often are unable to distinguish between anxiety and restlessness, and he warns that “indications of anxiety-like symptoms” such as “uneasiness,” “hyperactivity,” “pacing,” “vague complaints about medication,” and “insomnia” may be subtle reflections of akathisia. It is the purpose of this paper to stress the clinical importance of this side effect and to aid the clinician in its detection.